Failure to Report Unexpected Resident Death and Investigate Change in Condition
Penalty
Summary
The facility failed to identify and report an unexpected death of a resident to the State Hotline, law enforcement, and the coroner as required by reporting guidelines. The resident, who had diagnoses including congestive heart failure and cellulitis, was admitted cognitively intact and was not expected to pass away. On the day of the incident, multiple nursing assistants observed significant changes in the resident's condition, such as slurred speech, a swollen arm, and inability to track with their eyes. These concerns were repeatedly reported to the assigned nurse, who did not assess the resident or take appropriate action. Staff had to insist that the nurse check on the resident and contact emergency services. After the resident's death, staff expressed concerns about the nurse's lack of clinical judgment and urgency to both the DON and other supervisors. Despite these events, the facility did not log the incident in the reporting log, notify the State Hotline, law enforcement, or the coroner, as required. The DON and administrator did not conduct a thorough investigation or collect staff statements, and the DON admitted to not consulting the facility's reporting guidelines. Staff interviews revealed that concerns about the nurse's performance were known but not acted upon, and staff were discouraged from escalating the issue. The lack of reporting and investigation prevented the identification of potential abuse or neglect related to the resident's unexpected death.